Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

Ann's column was right on target and entertaining, as well. The second one was quite informative and interesting but not nearly as colorful. I like Ann, she gets too big for her britches sometimes, but it's hard to be "RIGHT" all the time. (Sorry for the bad pun, couldn't help myself.)

I've been lurking here for quite a while--you guys always keep it interesting.

911, that was a particularly lame response. You really know so little about Coulter that you don't know she's a bigot and seller of hate?

Try Googling her for quotes, you can start with these:

"We should invade their countries, kill their leaders and convert them to Christianity." (Sept. 12 2001 when no one was joking about anything.)------------------------About the 9/11 widows: "These broads are millionaires, lionized on TV and in articles about them, reveling in their status as celebrities and stalked by grief-arazzis. I've never seen people enjoying their husbands' deaths so much."------------------------God says, "Earth is yours. Take it. Rape it. It's yours."

If this is the person you want in your bed, by all means take her. She's yours.

Liberals are by nature weak minded. They therefore label anyone who doesn't agree with their socialist moral relativistic outlook a bigot, racist, homophobe. I feel sorry for them, in the same way I would feel sorry for a deer with one gimp leg, knowing full well he is about to be eaten.

For every doctor making $200,000/year, there are 10 95-year-old intubated, demented, septic elderly blind people costing Medicare $25,000 per day in the ICU and 25 lawyers buzzing around waiting to sue the doctor if she dies.

Thoughts on the concept of on-line anonymity:The 'anonymous' above does not get the concept that an online persona, be it 911doc or other established bloggers, have a personality and reputation that is independent of their actual name and identity. If 911doc comes out as , for example, pro-Hitler, then I think he would lose readers. In other words, he (or she) has an established online reputation and persona that can be damaged by careless statements. You, anonymous, do not. QED.

Now, I am one of the few around here that doesn't spend my days in the ER yet (still a bit occupied cutting up dead people), but ER's are overcrowded, right? Seems like I heard that somewhere.

So it's weird that no one has commented on what is implied when Coulter says that the only problem in our healthcare system is that docs are paid too little. She doesn't see it as a problem that 40+ million people have no PCP (because they have no insurance), so when they get sick they just go see you guys.

It's so weird to me that the ER blog community is so right-leaning on health policy (my boys Shadowfax and Graham notwithstanding). If we could get a few more of the 40 million coverage, THEY WOULD LEAVE YOU ALONE!! You guys all (understandably) hate treating non-emergent patients, so why aren't you pulling for the rules to be changed so that you don't have to?

Just curious. Now I have to go back to memorizing the brachial plexus.

short answers: econ 101 and i don't want to be 'left alone' by patients.

longer rambling answer after a night shift...

you speak as if it were a simple matter of passing a law to generate coverage (that's what EMTALA is). where does the money come from and where does the incentive for personal responsibility fit in?

also, of the "40 million" uninsured there are many millions who are...1. in the country illegally.2. choose not to have coverage on an economic basis because they are young and otherwise healthy or would rather pay for their cigarettes/cell phone/plasma screen/ new car.3. a much smaller segment of the population who would pass the 'smell test' for being incapable of doing any more for themselves.

i'm not saying this for a laugh or to be classist, i'm saying it because people, being people, will not make financially difficult but responsible decisions (like actually picking up the phone and getting a PCP) unless there is a downside to poor decisions (which, right now, is having to wait 4 or 5 hours to get their care for 'free' in the ED).

i myself went from 21 years old to 26 years old with absolutely no medical coverage. why? i was young and healthy. i got lucky.

if we 'give' coverage to everyone or expand it to get 'more people covered' then where is the incentive to 1. maintain your health and make good health decicions and 2. see medical care as a privelege and not a right?

now you may think it is a right but if you do i expect you are also for a right to free food and the like as we certainly can't live without it and right now grocers and restaurants have the annoying habit of expecting people to pay for what they want and need.

i WISH that, when foks were given a pile of money (for really that's what we are talking about... money to finance 'free health care') directly out of their neighbor's pocket, that their response was "WOW!, i have done nothing to deserve this gift and am extremely lucky to have been born in america where 'the rich' (those making more than $80,000 a year as defined by our government) don't mind the government's hand digging deep into their pockets... i'm going to treat this gift with the utmost respect and not abuse it and i'm going to knock-off the cigarettes and wear my seat belt and only go to the ER when i'm truly ill and i will endeavor to make enough money someday to be one of the payers in this scheme so i can even the score." but guess what, this HAPPENS SO RARELY THAT WHEN IT DOES HOLLYWOOD MAKES A MOVIE ABOUT IT!

a little free stuff becomes more. a band aid becomes a bandage, then a splint, then a full body cast.

government wealth-redistribution programs (this is exactly what we are talking about) NEVER go away because they NEVER WORK to fix the problem they were NEVER designed to fix. they are like heroin to the users AND suppliers.

when you rotate through the VA hospital take a look and see who actually does the work there and which nurses are the best there and which doctors are the best there and see if you can get anything to happen there after 5pm or on the weekend. what you will find is that the work is done by the residents and medical students, that the government employees, who can not be fired without an act of God, work at exactly the same pace all the time (slow). try to generate in these lifers (with full benefits) a sense of urgency about your sick patients and notice that within a few days you decide that instead of asking the tech or nurse to draw labs and get an ekg on some poor old vet that you decide that, even though you have not slept in eighteen hours, you will just do it yourself or it will not get done till the next shift comes on.

why not look at the history of the super small and only-for-the-most-down-and-out program called social security? you may have heard of it. (obtw, when it comes time for you to sit down with a financial planner to do the responsible thing and plan how to pay-off your debt from school and plan for your family's long term finanincal and health needs, he or she will tell you that you should not figure social security into your calculations because you will never get it.)

or look at the government's little old program (only for a few really needy folks) called medicare/ medicaid?

rasmussen tells us that americans are big fans of universal coverage, or better coverage, but no one tells them that with this coverage they will get in line with citizens (and a host of others who have been deemed to have a right to the tax revenues of others) who have not bought supplemental insurance, and hope they make it the 8-12 months that will be required to schedule them for their CABG or liver transplant.

or try this. pick a wealthy neighborhood wherever you live and go knock on doors. ask the folks who answer if they would mind spotting you a hundred bucks so that you can get an Xray and an orho appointment for your injured knee. you only need ten people to give you the money and then you should be good to go. i wonder how many houses you'd have to visit? if you are not willing to do this then how can you ask 'the government' to do it for you or for whomever 'they' think 'deserves' it.

finally, you need to understand that i have absolutely no problem treating people with no coverage, it's what i signed up for and allowances have been made and i have planned accordingly. i never expected to get rich doing this. i drive a truck. i shop at target and eat at chilis for a treat.

the people we rail against have made an economic decision to forgo medical insurance not because they can't get it or can't afford it but because they know that they can get stuff 'free' right here in any good old american ED. this is then transferred as a very real time and monetary burden to physicians who also lose sleep and relationships and (fill in the blank) taking care of people who should know better and, in fact, DO KNOW BETTER.

understand, i am not a misanthrope, but i am a realist, and if you want your health care to be worth what other 'free' stuff is worth, then by all means, proceed. if you think the next 100 billion dollars thrown at the problem will fix it or even make it better then load up the old bong and turn up the grateful dead dude.

as for me, i want the best-trained physicians in the world to WANT to treat me and to be properly reimbursed and properly rested. i want the same from the guy that flies the 727 i'm on and the same from anyone i go to to get a product or a service. what's the best way to do this? treat the most talented and best like they are, in fact, what they are. don't punish them.

my auto mechanic is properly reimbursed, as is my dentist and my vet. so is ladanian thomlinson and so is matt damon. they are properly reimbursed because they work and compete in a largely free market. LT makes millions a year because, well, HE's WORTH IT to the people that pay him and he produces excellence.

i'm not sure why doctors, out of all professions, are demonized for complaining about having their profession and personal lives affected in a very real and daily way by people who expect us to give our time and unique services and skills to them. perhaps because we are working and don't have the time or the inclination to go on strike.

free stuff does not exist. forcing people to make decisions about what they can afford and not afford is capitalism. it works. removing financial responsibility will actually make the situation worse and doctors will vote with their feet out of the profession. watch as it happens.

Student doc: Chances are you have worked hard in a very goal directed way to get to the point where you are standing over that cadaver. Some people live their entire lives in a reactive way. They form the a large chunk of the uninsured. (The uninsured also includes an ever changing portion of people for whom it makes (risky) financial sense to be uncovered for a time). Coverage for that 40 million or so without it will not solve the problem. Many folk visiting the ER simply do not have the "what ever it takes" to organize themselves enough to call, make an appointment, and then follow through and make it to the appointment on time. That is why they also don't have a job, don't finish school, don't apply for government programs they are eligible for, and go on to fail in other ways. Coverage or not, they will still end up in the ER because they are unable to live in any but a reactive way. I like Ms Colter because she is so brassy. And usually right.ExER Doc

911: Incredible answer! You, my friend are more coherent after a night shift than I'll ever hope to be.

Student Doc: keep studying the brachial plexus, the circle of Willis, the cranial nerves, the autonomic nervous system, etc. Once you've invested literally hundreds hours of work into memorizing and understanding those things, get ready for your clinical rotations. Enjoy your 36 hours of scut work at a time 3 times a week preparing you to take your boards. Then, get ready for the fun and exciting 3 to 5 (or more) years of residency training making less than minimum wage (don't ever stop during residency to actually calculate your true hourly pay because you'll blow your brains out).

Once you've done the above, THEN come back to the forum and explain why you don't have a problem with people taking your time, knowledge, and expertise for granted and for free (whilst retaining the right to sue your happy ass if you make any mistakes). Maybe then, you'll understand.

If not, then come and spend a day with me and actually see and touch the throngs of people who demand their "free care" while sporting designer handbags (with a pack or two of cigarettes in the pocket), cell phones, and sneekers that cost more than any two pair of shoes that I own.

These people of whom 911 so eloquently speaks ARE real. These people are literally hundreds of specific faces to us, not abstract concepts.

Universal health coverage is a wonderful tag line. It is a caring campaign slogan. But it's also a massive government expenditure that will bring DOWN the level of care we can deliver to EVERY patient. Don't let yourself be fooled.

A few months ago, I had the pleasure of caring for a lovely lady from Quebec. She developed a pneumonia and was ill enough to require hospitalization. I overheard her talking to her husband about their insurance and whether she would have coverage in the US.

I stepped back into the room to assure her that her condition was a legitimate emergency and I would fill out any papers she needed in order to get the Canadian Healthcare System to pay the bill.

She just laughed at me and informed me that she and her husband paid for private health insurance saying: "God help anyone who relies on the Canadian Healthcare"!

ERDoc85: I'll be the first to admit that it's easy for me to be idealistic from up here in my enol-reeking ivory tower. I hear what you're saying. I know that the people you and 911 refer to are real. The thing is, so are the people I ride the bus with everyday who have holes in their shoes. I know you guys aren't heartless (cat notwithstanding :), and would/do gladly help the truly needy. So is it better to throw out the baby with the bath water? From my tower, the answer is no. I'll get back to you in 2015 with an answer from the trenches.

Charles/911: You're right, it took lots of hard work and long term thinking for you and I to get to where we are today, and if the welfare crowd had the same (fill in the blank quality) that we have, there would doubtless be fewer welfare cases out there. But my thing is (brace yourself, hippie/liberal/borderlinecommie comment coming), could I have had an advantage that the poor black kid in Watts didn't have? Did my parents (stable, productive middle class business owners) teach me something that his parents didn't teach him? I think so. Am I saying I don't think it's totally the fault of the uninsured that they are uninsured? Yes.

please forgive 'cat. he's had his soul nearly sucked out of him in the ED. i agree that there are those people on the bus. what you must understand is that the absolute WORST way to try and address the problem is to 'get the government to fix it'. see prior response. and no, i'm not interested in paying more in taxes thank you. right now my return per dollar to me and my family on the taxes i pay is fifteen cents. now, over the nearly fifty years that we have instituted HUGE government welfater and social programs i would like for you to tell me what has changed? does it strike you that, on a common sense level, a monthly handout just enough to live with plumbing and electricity and basic health care and food and a television and a car would likely motivate you? how about if we gave it to you as long as you lived? motivated?

you may be forgiven as i suspect you arer just out of some high powered university where economics is no longer taught and emotion and diversity rules. if you choose to stay in academia you can continue to avert your eyes. if not, we'll see ya in a few years.

I don't see welfare as a solution, I see it as a bandaid (possibly even a free one from your ED). I think that MAJOR change takes generations. So I think what you do is start funding education as if it could actually affect change. Pay teachers well. In Dallas public schools, a teacher w/20 yrs of experience makes less than $60K. Conservative doctors make the valid point that if we want the best and brightest to be doctors, we should compensate them accordingly. But I bet you would laugh if I suggested that public education would improve if a 20 yr teacher took home six figures. And please don't tell me there isn't room in the budget for it. If there's one thing we've learned since 9/11, it's that if it's important enough, we can pay for it.

So honestly answer this question: If we doubled teachers pay, and set the bar WAY higher for becoming a teacher, do you think it would help?

In the mean time, we have a bunch of old dogs that we're trying to teach the new trick of becoming stable and self sufficient. So here is where I start being a realist and say, no, they aren't going to magically figure it out, we should help them because we CAN.

And just fyi, it took me about five years in the real world to become a pinko liberal (after which I decided to go to med school....I just turned 31). I graduated from college as card carrying republican.

how could you possible be a pinko? i agree that paying teachers more is a great idea. i think single sex middle and junior high school is a good idea. i think raising the bar for every student rather than lowering it for all is a good idea and these are all conservative principles. you must have lived in boston, seattle, portland, san francisco, new york or someplace like those to have become a liberal in the 'real world'.

Yes, good old KS, home of the "Evolution is just a theory" sticker on high school biology textbooks.

Despite your thinly veiled condescension regarding my progressive views, I'm betting you can see how living in a state that tries every couple of years to teach intelligent design alongside of evolution could make a person vote for (gasp) Al Gore.

well now you've gone and done it. simply voting gore because he is the opposite of an intelligently designed being makes no sense to me. he says the 'planet has a fever'. well i've got a fever, a fever for MORE COWBELL! (sorry).

and as far as the evolution thing goes let's just let that be hashed out elsewhere, but consider (you may or may not have been following the 'atheism v theism' conversation my friend ETOTHEIPI and i are having under the post entitled "Tag, M.D.O.D. Contributors! Answers Please... ") that the Christianity i believe in explains both creation and evolution and it is a robust faith with evidence continuing to accumulate in support of the Bible as the archaelogists dig deeper and deeper.

evolution, even its most ardent proponents will admit (with the exception of dawkins who calls people who don't believe everything he says about it 'psychotic'), is evolving.

back in my undergrad days when dinosaurs roamed the earth evolution was seen as a gradual process. then, in med school, the idea of 'puncutational evolution' was needed to explain new additions to the fossil record and new evidence from genetics.

i myself am not an 'intelligent design' person, but i do respect their opinions. i do think the argument by design is a good one but is likely to be overcome as gaps in the genome and the fossil record are filled and then the intel. design. folks are going to be faced with a shrinking 'God of the gaps' as it has come to be known.

i would simply caution you not to form your opinion about those on the right wing by the rural Kansans with the bumber stickers you saw.

in return, i will endeavor to resolve to restrain myself from choking the living shit out of every stinking hippie crunchy driver with a 'buck fush' or 'visualize world peace' sticker on their cars.

In order to properly characterize teachers' compensation, it is necessary to also consider benefits, such as health insurance and retirement. Teachers in PA make an average of roughly $40K per year. However, most have no cost health insurance and fully funded retirement with 30 years service. As a physician, you will be making negative money (as you are now), then slave wages, then FINALLY a real salary. Don't forget your school loans, which will double-triple over your years of repayment. Once you finish, unless you are a military doc/VA, you will be responsible for your own health insurance/retirement payments.

The "teachers are undercompensated" argument is popular but (to me) unconvincing. When benefits are considered, teachers make similar salaries to others with bachelor's degrees (and most people don't have three months off per year.) I recall school administrators from my highschool days who were absurdly overpaid for the (nothing) they did.

anonymous. good point. i guess i would say that like any govt. bureaucracy much of the $$ spent on education goes to people who push papers around a desk. catholic schools do wonders with kids for much less. they have no telephone book size regulation book they have to follow and therefore need fewer administrators. they can also enforce rules more efficiently and discipline students without the fear of the RRReeevvverend Shaaapton showing up on the steps with a megaphone and hired protestors. i'm not saying send everyone to catholic school, i'm just sayin'...

Student Doc: You missed the point. You note the people on your bus who have holes in their shoes. We see those folks and feel sorry for them too.

That is NOT the group of people that we are referring to.

This is also the group that Medicaid is designed to help (for a limited time until they can get on their feet).

With years of experience dealing with people, insurance billing rules, governmental payments (Medicare and Medicaid), and VA patients and hospitals, we're telling you that the answer is NOT more government control.

As 911 said. Our "progressive" (liberal) Congress is trying to expand the SCHIP program to cover more of the "poor". Their definition of "poor" is less than $80,000/year! Anyone who opposes this idea is immediately labelled as "not caring about children". I think just the opposite is true.

On a seperate but related topic:

Did any of you see the Oprah Show last week with Lisa Ling? (No, I don't watch Oprah...I don't want Oldfart to think I had orchiectomies. But it was on was on in my dentist's office).

Michael Moore was on the show and Lisa Ling was telling sob stories about people who couldn't get necessary medical procedures because they had lost their insurance. I kept wondering where they found these people?

I don't know about any of the other practicing docs, but every day I see my colleagues performing needed procedures on patients who can't pay. Sure, there's the occasional Worker's Comp claim that few docs will take (another strike against more governmental involvement). And there's the occasional chronic pain patient that ortho doesn't want to touch, but they are the minority.

From my experience in several different hospitals, I just don't see that aspect of the "crisis

85: I get that you are talking about people who take advantage of welfare-type programs. My point is that there are truly needy people who are not getting help that even you agree they should get.

As far as the level of government involvement goes, this is the crux of the difference between conservatives and liberals, so there's not that much point in debating it into the ground. An observation though: Conservatives frequently decry government involvement in things such as healthcare, feeding the hungry, etc. But they rarely propose an alternative, which leads me to believe that they actually don't care. I'm not making a statement about you as an individual, but just in general.

911: It's not the catholic schools that are doing wonders with the kids. It is the involved, caring, stable parents. Kids from that background do great in public schools too.

Also, explain just briefly how ER docs get paid....do you not get paid for specific procedures if the patient is a deadbeat? Or is it just the fact that so many don't pay that inevitably drives your salary down?

Anon: 40K the first year out of undergrad = not bad! 48K the 14th year out = you're getting screwed royally. Would you stay in a job where the raises didn't come close to keeping pace with inflation?

And i really hope you're not implying that school administrators in general "do nothing". At my wife's school they frequently work 50+ hrs/wk, and then go to all the extracurricular events on top of that. Also, since when is 60-70K/yr "absurdly overpaid" for a professional position requiring at least a masters degree?

Would I stay in a job where raises did not match inflation? You are describing medicine! Despite rising costs, reimbursements either stay the same or decline. This is another problem with putting the govt in charge of the purse strings; they can tighten them at will and we have no recourse.

$48K with 14 years experience is too low. But I am not going to jump on the "poor teachers" bandwagon. My wife (BS degree) works as a researcher at a university, 50+ hours/week for $26K. We have to pay our own health insurance premiums and retirement (no NEA backing for us).

What are the admins at your wife's school doing for 50 hours/week? Are they working that whole time, or is that the time that they are in office? Where is the evidence that layers of admins filling out forms (sounds like a hospital!) improve education? You could pay teachers much more (and have more stringent entrance requirements) by eliminating some of the red tape. Also, I wouldn't call going to HS football games "work." I doubt that they have to attend every, or even most, events if they do not choose to do so.

alas, i grow tired because, dear student doctor, there is no easy answer to your problem. generally we get paid in two ways...

1. we sign on with an ED management group that pays us a fixed salary per hour and may or may not include benefits.

2. we sign on with a group that pays a 'base salary' with added $$ for procedures and 'critical care time' and complicated patients (the kind i'm working for now).

3. you sign on with a group that pays you strictly on productivity.

obviously, in scenario 1 there is no incentive to 'go fast'. in the latter two scenarios there is incentive to 'go fast'. then there appears the tension between seeing a lot of patients and not missing anything subtle. every ED doc solves this for themselves in a different way.

as for the hours workde by administrators i agree that they probably do log many hours. my question would be whether what they produce has any value and if they work at maximum efficiency.

if every comittee at our hospital disbanded today exactly nothing would change and people would dance a jig.

SD: I hardly think that expecting and wanting people to accept personal responsibility is "not caring". They are seperate issues. One is mental, the other emotional.

My group pays a bit differently from 911.

Each of us receives the percentage we bill from the monthly collection pool. There is no place on our records that indicates whether or not a patient has insurance or the type. We don't need or want that information.

After my percentage of the "pie" is calculated, then the billing company takes 15%, the management company (who does absolutely nothing) takes 15%, then they subtract the monies paid to our director, assistant director, and secretary. Next they subtract the fee we pay for a scribe service.

We're getting screwed now, but will hopefully be able to correct it when the contract expires next year.